TB Notes Newsletter
No. 3, 2008
Release of New Civil Surgeon TB Technical Instructions
The new TB component of the Technical Instructions (TB TI) for
the Medical Examination of Aliens in the United States became
effective on May 1, 2008. These instructions, developed by the
Division of Global Migration and Quarantine (DGMQ) at CDC, supersede
the TB section of the June 1991 Technical Instructions.
Civil Surgeons are appointed by local offices of the Bureau of
U.S. Citizenship and Immigration Services (USCIS) and perform the
medical examinations of aliens in the United States. Aliens who
require medical examination include persons applying for adjustment
of immigration status (e.g., nonimmigrant visa holders) and other
persons requiring a medical examination as determined by the
Department of Homeland Security.
The new Civil Surgeon TB TI are to be used in conjunction with
the new I-693 form, which was released by USCIS on May 1, 2008. The
new I-693 form can be identified by the list of seven TB
classifications found at the bottom of its first page.
A letter was sent via e-mail to the National TB Controllers
Association on April 4, 2008, regarding the release of the new Civil
Surgeon TB TI.
Highlights of the major changes in this release of the Civil
Surgeon TB TI are as follows:
Sputum cultures for Mycobacterium tuberculosis, and drug
susceptibility testing for positive cultures, are required for
applicants with chest radiograph findings suggestive of active TB
disease. These new tests are mandatory, in addition to the
previously required sputum microscopy for acid fast bacteria. Health
department practitioners will decide if these tests are needed for
applicants with chest radiographs suggestive of inactive TB and for
applicants with clinical presentations consistent with TB.
Applicants with Class A (either smear or culture positive) TB
must complete a full course of TB treatment. Completion of therapy
is required prior to medical clearance for TB by the civil surgeon,
for purposes of this examination and the USCIS.
A chest radiograph is required for all applicants with a
tuberculin skin test (TST) reaction of 5 mm or greater of induration,
including pregnant (or possibly pregnant) women. Previously, the
chest radiograph could be waived for a pregnant applicant if she had
a scar or other evidence of BCG vaccination and denied having any
TB-related symptoms. This exception is no longer permissible. If the
applicant decides to undergo a radiograph during pregnancy, the
possible risks of radiation to the fetus should be explained to her
and informed consent obtained, confirmed by a signed consent form.
If she wishes, the applicant may defer the radiograph until after
delivery, but the civil surgeon cannot sign the medical examination
form until the radiograph is performed and interpreted, and
treatment for Class A pulmonary TB disease, if needed, is completed.
A chest radiograph is now required for applicants with a TST
reaction of less than 5 mm of induration (including no induration)
- Signs or symptoms consistent with active TB disease.
- Immunosuppression for any reason (e.g., HIV infection;
immunosuppressive therapy equivalent to or greater than 15 mg/day
of prednisone for one month or longer; or history of organ
Definitions of chest radiographic findings that are suggestive of
TB disease are provided to assist the civil surgeon in determining
the proper TB classification. These descriptions are presented in
Appendix B of the TB Technical Instructions.
A new TB classification (Class B: Latent TB Infection Needing
Evaluation for Treatment) should be used for all applicants who are
recent arrivals to the United States (less than 5 years) from
countries with a high TB prevalence, with a Mantoux TST reaction of
10 mm or greater of induration, and no evidence of TB disease. See
Section V of the TB Technical Instructions for other conditions for
which referral for evaluation for treatment of latent TB infection
is recommended. The civil surgeon should proactively contact the TB
control program of the local health department to identify specific
sources of treatment for latent TB infection and make the
Class B3 (consistent with old, healed TB disease) has been
TST Instructions. Appendix A includes directions for the proper
procedures that civil surgeons must follow in the storage of
purified protein derivative (PPD) and the administration and
interpretation of the TST.
The new Civil Surgeon TB TI state that QuantiFERON is not
currently accepted in place of a TST. When additional information is
available, an update to the civil surgeon TB TI will be posted on
the DGMQ website. We expect this update to be available in 2009,
following a consultancy sponsored by DTBE and other steps necessary
to provide information to civil surgeons so that they may best
utilize the test.
The following documents can be found on the
- The new civil surgeon TB Technical Instructions.
- A memo to civil surgeons concerning the new TB Technical
- Frequently Asked Questions (FAQs) regarding the new Civil
Surgeon TB Technical Instructions.
The above website also contains links to the 1991 Technical
Instructions for the non-TB portions of the medical examination
(other infectious diseases, mental health conditions, etc.) and to
the Vaccination Technical Instructions. Civil surgeons should
continue to follow these other Technical Instructions for the non-TB
portions of the examination. Updates to the Technical Instructions
are found at the same site.
The I-693 Form is not distributed by CDC/DGMQ. It is available on
the USCIS website.
If, after consulting the above website, clarification or further
guidance is needed, CDC/DGMQ may be contacted via fax at (404)
639-4441. The fax should be addressed to “Civil Surgeon TB Technical
Instructions.” Alternatively, Dr. Mary Naughton can be contacted at
—Reported by Mary Naughton, MD, MPH
Div of Global Migration and Quarantine